Head injury that results in a high minute ventilation and hyperventilation is sometimes difficult to control, regardless of the mode selected. Some patients with brain injury have a tendency to breath with a high tidal volume and rate, which is due to a central nervous system lesion and cannot be corrected.1. True 2. False

True

Common causes of metabolic alkalosis include all of the following except ____.1. loss of gastric fluid and stomach acids (vomiting, nasogastric suctioning) 2. acid loss in the urine (diuretic administration) 3. mechanical ventilation 4. acid shift into the cells (potassium deficiency)

mechanical ventilation

In the presence of fever, burns, multiple trauma, sepsis, hyperthyroidism, muscle tremors or seizures, agitation, and multiple surgical procedures, it is not unusual for metabolism to be high. In these situations the elevated ____ is due to the increased metabolic rate.1. FIO22. mean airway pressure 3. VCO24. PIP

VC02

Hyperventilation may be needed for brief periods when acute neurological deterioration is present and ICP is elevated. Mild hyperventilation (PaCO2 30 - 35 mm Hg) may be used for longer periods in situations where increased ICP is refractory to standard treatment.1. False 2. True

The time spent suctioning is brief and must not exceed 15 seconds. Suction is applied intermittently rather than continuously, and the catheter is rotated as it is withdrawn.1. False2. True

True

The intent of saline lavage is to loosen secretions; however, saline does not thin secretions, and instilling saline may increase the risk of dislodging bacteria from the endotracheal tube, causing them to enter the patient's airway and potentially leading to nosocomial pneumonia.1. False 2. True

True

During mechanical ventilation of a patient with COPD, the PaO2 = 58 mm Hg and the FIO2 = 0.50. If the desired PCO2 is 65, then the FIO2 must be changed to ____.1. 0.56 2. 0.44 3. 0.65 4. 0.74

0.44

During mechanical ventilation of a patient with CHF, the PaO2 = 38 mm Hg and the FIO2 = 0.60. If the desired PCO2 is 60, then the FIO2 must be changed to ____.1. 0.74 2. 0.95 3. 0.64 4. 0.38

0.38

During mechanical ventilation of a patient with CHF, the PaO2= 48 mm Hg, the FIO2 = 0.60, and the PEEP is 5 cm H2O. If the desired PCO2 is 60, then the FIO2 must be changed to ____.1. 0.66 2. 1.00 3. 0.85 4. 0.75

0.66

It is important to try and keep FIO2 below 0.4 to 0.5 to prevent the complications of O2 toxicity, while keeping the partial pressure of O2 in the arteries (PaO2) between 60 and 90 mm Hg and the CaO2 near normal (20 mL/dL).1. False 2. True

True

Factors that increase Paw during PPV include all of the following except ____.1. increased f 2. increased FIO23. increased total PEEP 4. increased PIP

increased FIO2

Atelectasis is the partial or complete collapse of previously expanded areas of the lung, producing a shrunken, airless state. It may be caused by all of the following except ____.1. alveolar hyperinflation 2. blockage of air passages 3. shallow breathing with increased FIO24. surfactant deficiency

alveolar hyperinflation

The positive pressure employed with CPAP or PEEP is commonly applied to the airway with all of the following devices except ____.1. esophageal obturator 2. a tight fitting mask 3. endotracheal tube 4. nasal prongs

The use of PEEP allows for the reduction of FIO2 because PEEP improves oxygenation and helps to avoid the complications associated with a high FIO2 in certain disorders. Specific clinical disorders that may benefit from the use of PEEP include all of the following except ____.1. bilateral diffuse pneumonia 2. cardiogenic pulmonary edema 3. ALI or ARDS 4. carbon monoxide poisoning

carbon monoxide poisoning

Patients' clinical conditions that indicate that PEEP or CPAP therapy be started as soon as possible include all of the following conditions except ____.1. pathological conditions with FIO2 values ³0.5 2. pathological conditions with high compliance 3. pathological conditions that damage pulmonary cells (types I and II) 4. high peak pressures (>35 cm H2O)

pathological conditions with high compliance

A clinician is asked to reduce the PEEP that the patient has been receiving from 10 to 5 cm H2O, using an older-generation ventilator. After the adjustment is made, the ventilator begins initiating inspiration spontaneously (auto-cycling). Which of the following best explains this malfunction?1. The sensitivity control needed to be reset after PEEP was adjusted. 2. The peak flow control is probably not adjusted properly. 3. The respiratory rate should have been reset after PEEP was adjusted. 4. The pressure limit was not reset after PEEP was adjusted.

The sensitivity control needed to be reset after PEEP was adjusted.

A patient is receiving 10 cm H2O PEEP with an FIO2 of 0.40. The patient is hypoxemic and the clinician decides to increase the PEEP to 15 cm H2O and maintain the FIO2. The subsequent cardiac output measurement shows a change from 4.5 to 2.7 L/min. The most appropriate action is to ____.1. apply PEEP at 20 cm H2O and maintain the FIO2 at 0.40 2. discontinue PEEP, set the FIO2 at 1.0, and obtain an ABG sample in 30 minutes 3. apply PEEP at 10 cm H2O and increase the FIO2 to 0.50 4. apply PEEP at 5 cm H2O and maintain the FIO2 at 0.40

apply PEEP at 10 cm H2O and increase the FIO2 to 0.50

If cardiac output is low, O2 transport may be enhanced by all of the following methods except ____.1. slightly reducing the PEEP level 2. using beta-blocking agents 3. using volume loading (administration of fluids) 4. using inotropic agents

using beta-blocking agents

Despite risk, it is still important to use PEEP, since it can prevent alveolar collapse during exhalation and reopening even when a low Vt setting is used. It is now theorized that it is important to use the pressure-volume loop to set PEEP ____.1. at the peak inspiration point detected during inflation of the lung 2. at the lower inflection point detected during inflation of the lung 3. at the upper inflection point detected during inflation of the lung 4. above the upper inflection point detected during deflation of the lung

above the upper inflection point detected during deflation of the lung

In primary ARDS (direct), lungs are mostly consolidated. In secondary ARDS (indirect), alveolar collapse is predominant. A lung recruitment maneuver is less likely to improve oxygenation and compliance of the lung in secondary ARDS.1. True 2. False

False

Several types of recruitment maneuvers are currently being used in the clinical setting. These include a sustained high pressure in the CPAP mode, PCV with a single high PEEP level imposed, PCV with progressive increases in PEEP level, and sigh maneuvers.1. True 2. False

True

The ARDS Network trial and other studies provide strong evidence in support of using VT of 6 mL/kg and a Pplateau <30 cm H2O when ventilating patients with ARDS. The differences in survival are significant when these settings are used compared with using a VT of 12 mL/kg.1. True 2. False

True

Relaxation of smooth airway muscle in the presence of reversible airflow obstruction is a general indication for the use of:1. Antiinfective agents 2. Steroids 3. Adrenergic bronchodilators 4. Mucolytics

Adrenergic bronchodilators

Ipratropium agents may be indicated to treat:1. Nonallergic rhinitis 2. The common cold 3. Allergic rhinitis 4. All of the above

Nonallergic rhinitisThe common coldAllergic rhinitis***All of the above***

The keyhole theory indicates that the larger the side-chain attachment to a catechol base, the:1. Shorter the duration of action 2. More easily it is metabolized 3. More easily it is broken down by COMT 4. Greater the b2 specificity

Greater the b2 specificity

Albuterol is available in which of the following forms?I. SyrupII. Nebulizer solutionIII. Metered dose inhaler (MDI)IV. Oral tabletsV. Dry powder inhaler (DPI) capsules1. I, II, and V only 2. I, II, III, IV, and V 3. II and III only 4. III, IV, and V only

I, II, III, IV, and V

Inhalation is the preferred route of administering catecholamines for which of the following reasons?I. Rapid onset of actionII. Smaller dosage usedIII. Reduced side effectsIV. Drug is delivered to target organV. Safe and painless route1. I, III, and V only 2. I, II, III, IV, and V 3. III and IV only 4. I and II only

I, II, III, IV, and V

You receive an order to administer 5 ml of albuterol by small volume nebulizer (SVN). You would:1. Give 0.5 ml of medication because that is probably what the doctor meant to write 2. Confirm the order on the chart and administer as directed 3. Call the physician to confirm the medication dose 4. Have your supervisor administer the treatment

Call the physician to confirm the medication dose

A patient with glottic edema is in mild distress. Which of the following medications would be of benefit in this situation?1. Ipratropium bromide 2. Albuterol 3. Racemic epinephrine 4. Theophylline

Racemic epinephrine

Ipratropium bromide can be delivered by which of the following methods?I. TabletII. NebulizerIII. InjectionIV. MDIV. Nasal spray1. II only 2. I, III, and IV only 3. II, IV, and V only 4. I, II, and IV only

II, IV, and V only

Sedation is frequently required for mechanically ventilated patients for agitation and sleep deprivation, which can result from all of factors below except ____.

Propofol (Diprivan) is an intravenous, general anesthetic agent that possesses sedative, amnesic, and hypnotic properties at low doses, although it has no analgesic properties.

1. True 2. False

True

An appropriate depolarizing agent for use during intubation is ____.

1. Pavulon 2. Fentanyl 3. Vecuronium 4. Succinylcholine

Succinylcholine

NMBAs should not be used with sedatives for patients on mechanical ventilation.

1. False 2. True

False

A fresh postoperative patient displaying ventilator dysynchrony should first be treated with ____.

1. NMBAs 2. analgesics 3. sedatives 4. neuroleptics

analgesics

The most potent analgesic agent is ____.

1. Demerol HCl 2. Fentanyl 3. morphine sulfate 4. Dilaudid

Fentanyl

Nondepolarizing agents resemble acetylcholine in their chemical structure. These drugs induce paralysis by binding to acetylcholine receptors and causing prolonged depolarization of the motor end plate.

1. False 2. True

False

Regardless of the NMBA used, it is important to understand that these drugs do not possess sedative or analgesic properties and must, therefore, be used in conjunction with adequate amounts of sedatives and analgesics to ensure patient comfort.

1. True 2. False

True

NMBAs are commonly used in mechanically ventilated patients when ____.

A patient exhibits delirium characterized by disorganized thinking and unnecessary motor activity after being on a ventilator in the ICU for 4 days. The drug type appropriate to treat this condition is a(n) ____.

1. neuroleptic 2. sedative 3. analgesic 4. NMBA

neuroleptic

Fentanyl exerts significant effects on the cardiovascular system but does not cause histamine release like morphine.

1. True 2. False

False

Fentanyl citrate (Sublimaze) is a synthetic opioid that is approximately 100 to 150 times more potent than morphine.

1. False 2. True

True

Morphine is a potent opioid analgesic agent that is the preferred agent for analgesic intermittent therapy for mechanically ventilated patients because of ____.

1. its ability to alter the control of breathing 2. its effects on the central nervous system 3. its benign cardiac effects 4. its longer duration of action

its longer duration of action

Although the primary pharmacological action of opioids is to relieve pain, these drugs can also provide significant secondary sedative and anxiolytic effects, which are mediated through two types of opioid receptors: µ and ê receptors.

1. True 2. False

True

Reversal of opioid side effects can be accomplished with the opioid antagonist ____.

Observing the patient's skeletal muscle movements and respiratory effort can provide an easy method to determine if the patient is paralyzed with NMBAs; however, more sophisticated electronic monitoring is typically required to determine the depth of paralysis.

1. True 2. False

True

____ is a rare but potentially fatal disorder that is characterized by sustained skeletal muscle depolarization.

Vecuronium bromide (Norcuron) is an intermediate duration nondepolarizing aminosteroid NMBA that does not possess the vagolytic properties of pancuronium.

1. False 2. True

True

It has been known for several decades that PPV decreases cardiac output. This phenomenon can be understood in part by comparing intrapleural (intrathoracic) pressure changes that occur during normal spontaneous negative pressure breathing and intrapleural (intrathoracic) pressure changes that occur during positive pressure ventilation.

1. False 2. True

True

PEEP with assist/control decreases cardiac output less than when PEEP is used with IMV/SIMV or CPAP alone.

1. True 2. False

True

During spontaneous breathing, the fall in intrapleural (intrathoracic) pressure that draws air into the lungs during inspiration also draws blood into the major thoracic vessels and heart. This phenomenon increases ____.

It is unusual to see a reduction in cardiac output in normovolemic patients when low levels of PEEP are used (i.e., 5 to 10 cm H2O of PEEP).

1. True 2. False

True

Patients with very stiff lungs, such as those with ARDS or pulmonary fibrosis, receiving positive pressure ventilation are ____.

1. more likely to experience hemodynamic changes with high pressures 2. less likely to transmit alveolar pressure to the intrapleural space 3. more likely to have higher intrapleural pressures 4. less likely to have decreased lung compliance

less likely to transmit alveolar pressure to the intrapleural space

Maintaining the lowest possible mean airway pressure helps to minimize the reductions in cardiac output that can occur during mechanical ventilation.

1. False 2. True

True

Positive pressure ventilation and PEEP can be beneficial for patients with left ventricular dysfunction and elevated filling pressures for all of the following reasons except ____.

PPV increases splanchnic resistance, decreases splanchnic venous outflow, and may contribute to gastric mucosal ischemia. This last change is one of the factors leading to increased incidence of ____, which are frequently seen in critically ill patients.

Prolonged alveolar over-distention from mechanical ventilation leads to the release of inflammatory mediators from the lungs that can cause failure of other organs of the body. This response has been termed ____.

1. biotrauma 2. barotrauma 3. volutrauma 4. atelectrauma

biotrauma

More recent evidence demonstrates that the repeated opening and closing of lung units generates shear stress, with direct tissue injury at the alveolar and pulmonary capillary level as well as the loss of surfactant from these unstable lung units. This injury is now termed ____.

1. volutrauma 2. atelectrauma 3. biotrauma 4. barotrauma

atelectrauma 100%

The term ____, in general, is used when referring to lung injury occurring in humans that has been identified as a consequence of mechanical ventilation.

1. VALI 2. ARDS 3. VILI 4. VAPS

VALI

A condition that can be accelerated by mechanical ventilation is ____. It can be detected by a hyperresonant percussion note and absence of breath sounds on the affected side of the thorax.

____ occurs when an alveolus that is normally expanded is adjacent to one that is collapsed (atelectasis) and unstable. As airway pressure increases during inspiration, the normal alveolus inflates, but the collapsed unit does not.

1. Absorption injury 2. Volutrauma 3. Emphysema 4. Shear stress

Shear stress

Chemical mediators produced in the lung during ventilator mismanagement can leak into the blood vessels. The pulmonary circulation then carries these stimulating substances to other areas of the body and sets up an inflammatory reaction in other organs such as the kidneys, gut, and liver.

1. True 2. False

True

Mechanical ventilation is not benign and may cause lung injury. Treating patients with lung-protective strategies includes all of the following except ____.

1. low FIO2 2. low Vt 3. permissive hypercapnea 4. therapeutic PEEP

low FIO2

It is generally considered important in mechanical ventilation of patients with ALI and/or ARDS to open alveoli with a recruitment maneuver and keep them open with an appropriate level of PEEP.

1. False 2. True

True

The positive effects of PEEP in ALI and ARDS include all of the following except ____.

1. improved oxygenation 2. improvement of the V/Q relationships of the lungs 3. decreased CVP and right ventricle preload 4. FRC is increased when collapsed alveoli open up

Strategies for reducing the risk for colonization and VAP include all of the following except ____.

1. saline instillation into the ET tube during suctioning. 2. semirecumbent positioning of patient 3. handwashing and use of accepted infection control procedures and practices and use of closed suction catheters and sterile suction technique 4. continuous aspiration of subglottic secretions

saline instillation into the ET tube during suctioning.

The easiest way to detect air trapping or auto-PEEP is to evaluate ____.

1. the manometer PIP 2. the volume-time curve on the ventilator graphic 3. the flow-time curve on the ventilator graphic 4. the pressure-time curve on the ventilator graphic

the flow-time curve on the ventilator graphic

Management of patient-ventilator asynchrony begins with several specific steps. The initial step is to ____.

If a tension pneumothorax is strongly suspected and death is imminent, the appropriate next step is to ____.

1. confirm the finding with a chest radiograph 2. insert a 14- or 16-gauge needle into the second intercostal space at the midclavicular line 3. obtain a 7 Fr trocar and establish a pleural drainage tube 4. use a Heimlich chest drainage valve with chest tube placement

insert a 14- or 16-gauge needle into the second intercostal space at the midclavicular line

Wheezing associated with increased Raw from airway reactivity, such as occurs with asthma, is treated with all of the following except ____.

Asynchronous breathing may occur when patients with COPD are ventilated with PSV. These patients are known to have an active short inspiration. If the patient begins to actively exhale during the inspiratory phase of PSV, this can be corrected by ____.

1. switching to a ventilator with adjustable pressure-cycling characteristics 2. switching to a ventilator with adjustable flow-cycling characteristics 3. switching to PRVC 4. switching to VC-CMV

switching to a ventilator with adjustable flow-cycling characteristics

Conditions leading to high pressure alarms can be divided into all of the following categories except ____.

When compared with patients with COPD receiving only conventional medical therapy (such as bronchodilators, antiinflammatory agents, oxygen, and antibiotics), patients with COPD receiving NPPV have shown significant improvement in vital signs, pH and blood gas values, respiratory rate, and breathlessness within the first hour of application.

1. True 2. False

True

A number of studies have found that NPPV is currently considered a standard of care to treat ____ in selected patients.

When NPPV was compared with CPAP in the treatment of CPE, patients treated with NPPV had more rapid improvements in PaCO2 and pH, but mortality rates and intubation rates were not significantly different.

1. True 2. False

True

NPPV can be useful in chronic cases as supportive therapy for all the following clinical disorders except ____.

When is ventilator dependence likely to occur?I. when ventilatory capacity exceeds demandII. when arterial hypoxemia is presentIII. when the patient is malnourishedIV. when the cardiovascular system is unstable

1. II and IV 2. II, III, and IV 3. I, II, and III 4. III and IV

II, III, and IV

All of the following indicate that an adult patient is ready to be weaned from ventilatory support except:

Which of the following five adult patients receiving ventilatory support is the best candidate for weaning?Maximum voluntaryPatient VC VE ventilation (MVV) MIP VD/VTQs/QT

1.54.69.9-33

Which of the following patients exhibits an acceptable ventilatory demand?VEPaCO2

836

A patient has an adequate ventilatory reserve if which of the following is TRUE?

ability to double the resting minute ventilation

You measure the spontaneous rate of breathing and VT on four patients receiving ventilator support. For which one is successful weaning most likely?Breathing frequency VT

29350

A patient receiving ventilator support has a spontaneous rate of breathing of 26/min and an average VT of 300 ml. What is this patient's rapid-shallow breathing index?

1. 12 2. 87 3. 66 4. 105

87

Which of the following signs observed on a mechanically ventilated patient indicate that successful weaning is unlikely?I. palpable scalene muscle use during inspirationII. palpable abdominal tensing during expirationIII. presence of an irregular breathing patternIV. patient unable to alter breathing pattern on command

Which of the following must you verify when considering weaning an obtunded patient?I. adequate gag reflexII. no depressant drugsIII. adequate cough

1. II and III 2. I and III 3. I and II 4. I, II, and III

I, II, and III

Common approaches used to wean patients from ventilatory support include which of the following?I. T-tube alternating with mechanical ventilationII. pressure-supported ventilation (PSV)III. intermittent mandatory ventilation

An alert patient receiving intermittent mandatory ventilation at a rate of 8/min and VT of 600 ml has stable vital signs and satisfactory blood gases on an FIO2 of 0.45. What would you do to initiate weaning for this patient?

A physician is using a pressure support protocol to wean a patient off ventilatory support. The patient is now at a 5 cm H2O pressure level and has a spontaneous respiratory rate of 21/min. Other cardiovascular and respiratory signs indicate that the patient remains stable. Which of the following actions would you recommend at this point?

An alert patient receiving ventilatory support through a demand flow intermittent mandatory ventilation system exhibits clinical signs of an increased work of breathing whenever you try to decrease the mandatory rate below 6/min. In order to aid in weaning this patient, which of the following would you recommend?

Which of the following ventilator modes can ensure delivery of a preset VT during spontaneous breathing?I. volume support or VERSUS (Siemens Servo Ventilator 300)II. volume-assured pressure support or VAPS (Bird 8400ST)III. augmented minute ventilation or MMV (Bear 1000)

1. I, II, and III 2. II and III 3. I and II 4. I and III

I and II

Limitations of noninvasive positive-pressure ventilation include all of the following except it:

In most weaning protocols, what minimum blood gas parameters are needed to start the process?

1. PaO2 greater than 70 mm Hg and PaCO2 less than 70 mm Hg on FIO2 less than 0.6 and PEEP 5 cm H2O or greater 2. PaO2 greater than 70 mm Hg and PaCO2 less than 50 mm Hg on FIO2 less than 0.6 and PEEP less than 5 cm H2O 3. PaO2 greater than 50 mm Hg and PaCO2 less than 50 mm Hg on FIO2 less than 0.6 and PEEP less than 10 cm H2O 4. PaO2 greater than 70 mm Hg and PaCO2 less than 50 mm Hg on FIO2 less than 0.4 and PEEP 5 cm H2O or greater

PaO2 greater than 70 mm Hg and PaCO2 less than 50 mm Hg on FIO2 less than 0.4 and PEEP 5 cm H2O or greater

All of the following are disadvantages of using the T-tube method for weaning except:

While monitoring a patient being weaned by intermittent mandatory ventilation, you notice the following: total minute ventilation = 12 L/min; set (machine) minute ventilation = 5 L/min; set rate = 10/min; total rate = 20/min. What is the patient's average spontaneous VT?

1. 800 ml 2. 600 ml 3. 500 ml 4. 700 ml

700 ml

Which of the following cardiovascular changes would you consider a bad sign during weaning a patient from ventilatory support?

1. development of chest pain 2. increase in both stroke volume and cardiac index 3. fall in blood pressure from 143/95 to 126/88 mm Hg 4. increase in heart rate from 95 to 110/min

development of chest pain

While monitoring a patient being weaned through a T-tube protocol, signs indicating that mechanical ventilation should be restored include all of the following except:

Which of the following changes can be expected when weaning a patient through a T-tube trial?I. increase in respiratory rate of 10/minII. increase in heart rate of 15 to 20/minIII. 5 to 10 mm Hg rise in the arterial PCO2IV. doubling of the minute ventilation

1. II and IV 2. III and IV 3. I, II, III, and IV 4. I, II, and III

I, II, and III

While monitoring a patient during a T-tube weaning trial, you notice the following: increased patient agitation; increased heart rate (from 90 to 118/min); increased respiratory rate (from 17 to 33/min with some paradoxical motion); and premature ventricular contractions (PVCs) increasing to an average of 5/min. Which of the following actions would be appropriate at this time?

1. Reconnect the patient to the ventilator with prior settings. 2. Request that the patient be given a strong sedative or hypnotic. 3. Request that the patient be given a stat (immediate) bolus of lidocaine. 4. Encourage the patient to relax, and continue careful monitoring.

Reconnect the patient to the ventilator with prior settings.

Which of the following is FALSE about artificial tracheal airways and weaning?

1. The added work due to artificial airways can increase ventilator dependence. 2. Artificial airways can increase the work of breathing nearly threefold. 3. There are decreases in tube inner diameter (ID) and increases in VE increase the work of breathing. 4. Tracheostomy tubes increase the work of breathing more than can endotracheal tubes.

Tracheostomy tubes increase the work of breathing more than can endotracheal tubes.

What is the best way to decrease the work of breathing imposed by an artificial airway on a patient receiving ventilatory support?

Which of the following patients are at high risk for severe laryngeal edema after an endotracheal tube extubation?I. pediatric burn victimII. patient with epiglottitisIII. smoke inhalation patientIV. pulmonary fibrosis patient

1. I, II, and III 2. II and IV 3. III and IV 4. I, II, III, and IV

I, II, and III

Common causes for weaning failure include all of the following except: